Quality
Nurses Make 2010 a Banner Year for Accreditation
The University of Chicago Medical Center had one of its most successful years in terms of accreditation and much of the credit can be given to its nurses, said Krista Curell, Esq., RN, vice president of Risk Management, Patient Safety and Compliance.
The Joint Commission survey was the hospital's best yet and resulted in full accreditation. Nurses were critical players in the Joint Commission survey, spending the most time talking to surveyors and answering difficult questions about patient care, standards and hospital policies and procedures.
All clinicians are required to comply with certain standards in their day-to-day practice to ensure the hospital maintains a constant state of readiness for Joint Commission surveys, which take place every three years, said Curell. But nurses on every unit also participate in a tracer program, which tracks the course of four patients' care each month and assesses the Medical Center's compliance with Joint Commission standards.
Data from the tracer program is submitted monthly and serves two important purposes, said Curell. First, it ensures the Medical Center is providing safe, quality care and is ready for a successful survey. It also provides proof that the Medical Center is in a constant state of compliance to counter any incidental findings during an active survey.
The Medical Center also received full accreditation for its decentralized laboratories from the Commission on Laboratory Accreditation of the College of American Pathologists (CAP) in November 2009. Not all labs are CAP accredited and the survey is voluntary. During the CAP accreditation process, inspectors examine each facet of the decentralized laboratory's records including staff competency and training, testing techniques and quality control systems.
Since nurses are at the frontline of care and involved in point-of-care testing, they are key in acquiring CAP accreditation, Curell said. And the CAP survey process, much like the Joint Commission, also involved a lot of time interviewing nurses.
"Our nurses and nursing leadership did a fantastic job of earning the Medical Center full accreditation during both of these surveys," Curell said. "And it is important to recognize that our nursing staff is out there every day, complying with—and in many cases exceeding—these quality-of-care standards."
